Capoeira

In the warm-up sequence in the Rushfit workouts there is one exercise based on capoeira, a Brazilian style of dance and martial arts. According to the wikipedia article, capoeira was invented starting in the sixteenth century, mainly by escaped slaves and their descendants. Here is a marvelous video clip of two master capoeiristas. There was a somewhat similar situation with yoga in colonial India; for some practitioners it was a martial arts program disguised as a self-improvement regimen.

Good News Part 1: DXA

One of the unnecessary scares at the time of a physical exam took place in 2003, the first year I had a DXA scan to measure bone density. I went to a testing center where an MRI was administered and later interpreted by a doctor. The results revealed significant bone loss in the lumbar spine and left femur. I was horrified. My PCP wanted me to take Fosamax; I decided to get a second opinion.

I went to the radiologist who did (and still does) my mammograms. The results on his machine were significantly better than on the first test. The radiologist explained that readings can differ from one machine to another. There is also a margin of error for any machine so that small differences are not considered significant. (Since 2003 I’ve had five DXAs since then and none has ever given results as low as the first one.)  The overall picture was not too bad. The reading for the spine was definitely in osteopenia territory, those for the femurs were normal.

In the succeeding years the picture has stayed about the same: osteopenia in the spine but no worse than before, some additional bone loss in the hips but just barely out of the normal range. Last year the spine was somewhat better, the femur readings a bit worse. This year the spine was back down but the right hip (the side with the shorter leg) had increased 3.7%. So the overall picture is that the numbers bounce around a bit but not much changes. After ten years, is it really worthwhile for me to continue with these tests?

Clearly, my body can still rebuild bone. To help the process along I’ve decided to increase my calcium supplement intake by 25%. I also take vitamin D and magnesium along with the calcium. There has been a lot of talk lately about people taking too much calcium. The theory is that the excess mineral can harden the walls of the arteries and contribute to heart disease. But how can we know whether a particular person is getting more than enough without a blood test? We’re all different. In my own case, I take well over the recommended amount yet my serum level is at the low end of normal. My blood pressure is low normal and my cholesterol readings are just fine. Instead of making sweeping generalizations, I wish the experts would recommend that people get themselves tested. That is the scientific way, after all.

A Blast from my Dental Past plus Coping with Medical Procedures

I emerged unscathed from my annual physical (more about that in future posts) but a few weeks ago I started getting worrisome messages from my mouth. Nothing hurt, but whenever I aimed the water pick at my upper right molars, there was blood. When it comes to problems with teeth, I am super-vigilant because my dental past is checkered, to say the least. 

From my early teens to my mid-thirties there was one crisis after another: large cavities requiring extensive excavation, abscessed molars, root canals, and extractions. Heredity and stress probably contributed to this and I probably could have taken better care of my teeth, plus the fact that I was a smoker then. When I moved to Bloomington somebody put me in touch with The SuperDentist. He got right to work fixing up the damage done by neglect and less-than-successful remedies by previous dentists. The SuperDentist (now retired, alas) is a master craftsman; when his patients would move to other parts of the country their new dentists would ask, “Where did you get that wonderful dental work?” After a few years, during which I also quit smoking and my stressful job, my teeth stabilized. Apart from replacing the occasional old filling, there was not much to be done. 

(Side Note: There has been a lot of talk about whether silver amalgam fillings can cause high levels of mercury in the blood. For decades of my life I had a mouth full of those fillings, most of them replaced now. I also worked for a dentist one summer and mixed up the silver amalgam for him. This year I had my mercury level tested and it was very low. If anyone would have been harmed by silver amalgam, you would think it would have been dental workers. In the years before they wore masks all the time, clouds of dust from silver amalgam would be in their faces for much of their work day. Has anyone surveyed them?)

Anyway, I went to my regular dentist and he cleaned out a little something under the gum. Two days later, the bleeding started again so I went to my husband’s periodontist. MHP surveyed the situation. The bad news was that this was the beginning of periodontal disease. The good news was that it was early enough that he could do a laser procedure – no cutting, no sutures – that should take care of it. Since I’m always in favor of getting out in front of impending problems, I said “Let’s do it.”

I’ve had so many medical and dental procedures over the years that I’ve developed a routine that helps to reduce stress and anxiety. First, I try to get a good night’s sleep the night before. The next day I don’t do any strenuous exercise but I do a stretching routine, like the ones in RushFit and P90X. This gets my circulation going, which helps me relax and will promote healing. I wear layers of comfortable clothes, including a light sweater in case the office is over-air conditioned. I bring along something small to read, like a cell phone or paperback book, that can stay in my lap. When I’m waiting for the appointment or sitting by myself in the treatment room I don’t want to be staring off into space worrying about what comes next. Finally, following a tip from my grandmother, I focus on what I’m going to do afterwards.

Compared with many of my past dental adventures, the laser treatment was a piece of cake. There will be follow-up after a couple of weeks and then at longer intervals after that. I’m actually glad to get established with MHP because he will keep an eye on things so that I can avoid periodontal problems in the future.

Why I Always Get and Keep Copies of Medical Test Results

Yesterday was my annual physical, a day I always anticipate with dread because it represents my annual battle with The Way Things Are in the health care business today. Inevitably this battle involves my doctor, a kind and intelligent person who has only my best interests at heart. She is the one I would want beside me in a medical crisis. But there is no crisis – I am perfectly healthy – and this year, like most years, I will have to prove it, by achieving normal results on various medical tests or by justifying any result that is out of line.

I might give up having an annual physical at all, except that I need refills of the two medications I take regularly: Synthroid for my hypothyroidism (no generics, please, we’ve tried that already) and Premarin, which I’ve taken since 1980 because I had a complete hysterectomy and want to stave off bone loss. So I go for my physical, get my blood work, mammogram, and DEXA scan, and deal with the consequences. 

An individual test result, looked at in isolation, can be misleading. In health care, as in most of life, context is everything. Unfortunately, because of the way medicine is practiced today, context is very limited or absent altogether. Most doctors don’t know their patients well; many don’t know them at all. Record-keeping systems are constantly changing which can lead to the loss, misfiling, or intentional destruction of older documents. One topic of conversation with my doctor yesterday was my high BUN/creatinine ratio. This is an item to be taken seriously because it is an indicator of kidney function. In my case, creatinine is a perfectly respectable .9 (normal range .5 to 1.3) but BUN or blood urea nitrogen is a whopping 32 (normal 7 to 20), resulting in a ratio of 36 (normal 6 to 25). On a more positive note, my GFR, another measure of kidney function, is 66, perfectly fine.

My doctor was concerned but I pointed out that the ratio, for me, has been high for years, maybe even decades. In the past doctors have attributed the high BUN to dehydration associated with fasting before blood work. “Still,” the doctor said, “it’s higher than last year and the year before. It seems to be going up.” We talked about whether I’m dehydrated  (no), whether the protein supplement I take could be affecting it, and she wants me to repeat the test on a day when I’m not fasting. I agreed.

My doctor only has test results for me going back a couple of years but I started getting and keeping copies in 2000 when my doctor at the time wanted me to take statins. After my appointment I went back through the file and found that the BUN/creatinine ratio has bounced around a lot; in 2005 it was 36! Protein in the diet can have an impact on BUN; cardiosmart.org, the website of the American College of Cardiology says, "Do not eat a lot of meat or other protein in the 24 hours before having a blood urea nitrogen (BUN) test." Exercise can affect it too. One website for weight lifters recommends not lifting weights or doing cardio the day before the test. (I had probably done both the day before this year’s.)

I haven’t had the mammogram or DEXA yet but so far this year’s flap has been relatively minor compared with the breast cancer non-event a few years back and the heart disease false alarm last year. Doctors devote their lives to helping others. In order to help as many people as possible they rely on test results and on generalizations based on large research studies. Since their time with individual patients is very limited, they sometimes interpret idiosyncratic variations as disease. In addition to a very real concern for patients, the prevalence of malpractice litigation inclines doctors to err on the side of caution.

I believe that having health coaches in doctors’ offices would do a great deal to reduce unnecessary testing and anxiety on the part of both doctors and patients. A health coach would have the time to review my medical records and know that my white blood cell count is sometimes low and that my BUN is always high. Instead of making assumptions about my physical condition based on my age and sex, a health coach could actually find out how many pushups I can do and what I eat for breakfast. The main reason to respect Western medical care is that it is based on science and science depends on accurate information about specific situations. A health coach who knows me could be a valued ally in my annual fight to prove that I am healthy.

Working Out With Bob, Erik, and (of course) Tony

Anyone who reads this blog knows that I am a huge fan of P90X.  I first learned about the program from a Sunday morning infomercial on TV, bought the DVDs in September of 2009, and wasn’t sure I would ever be able to do the whole thing. I started interspersing some of the workouts with ones I was currently doing.  Eventually I did P90X Lean, the slightly scaled back version, all the way through. Last year I advanced to Classic, the main version, and did that all the way through twice. 

This year, when I started on my third round of P90X it occurred to me that I wasn’t getting as much out of some of the workouts as I had previously. One of the ideas behind the program is that muscle confusion prevents you from getting to a plateau so you keep making progress indefinitely. A survey of the reviews of P90X on Amazon l tells me that this is wishful thinking. With any resistance workout, no matter how intense and varied, sooner or later you reach a point of diminishing returns. (Cardio workouts are different: the body doesn’t seem to care whether you’re running, swimming, or on a machine. As long as you keep your heart rate up high enough, long enough, at the right intervals, you’ll keep your condition.)

I would like to have done P90X2, but it requires more space for exercising and for storing additional equipment than I have in my house. I looked at Insanity, another Beachbody program, but the amount of high impact activity seemed like a bad idea for my 67-year-old knees. I finally settled on two workouts by Bob Harper, who is one of the coaches on “The Biggest Loser,” and Rushfit, a six-DVD series featuring Canadian martial arts champion Georges St. Pierre and led by trainer Erik Owings, who created the program.  All of these are great workouts and each has its advantages and drawbacks.

So I’m now doing a combination of all three programs, trying to keep a variety of different types of exercise (as in P90X), while increasing the intensity. Each new workout you try uncovers unsuspected weak areas in your body that can be made stronger. Each one changes different parts of the body.  From P90X I’ve kept the four upper body routines plus Ab Ripper X. Upper body is really Tony Horton’s strongest area and you can tell that by looking at him. I also do Yoga X and Plyo X, which I alternate with the corresponding workouts in Rushfit.  “Balance & Agility” and “Stretching for Flexibility” are two bonus workouts in Rushfit that cover some of the same territory as Yoga X. “Explosive Power Training” is shorter than Plyo X but some of the moves are harder.

In the P90X workouts you are working out with Tony and a group of his friends. The mood ranges from serious to playful with Tony’s background in mime and standup comedy on full display. Tony seems genuinely interested in how each person in the class is doing and he introduces them all by name. He also does most of the workouts himself. In Rushfit you are being invited to share a workout that Georges St. Pierre is doing with trainer Erik Owings. The workouts all use the same warm-up and cool-down and all are based on a five-round cycle with short breaks in between, like a championship fight. As in P90X, the instructions are clear and there is a lot of attention given to correct form. I especially like Rushfit’s emphasis on fluid range of movement; "functional training" is the term Erik Owings uses to describe this approach. At one point he sits cross-legged on the ground, lifts himself onto his hands, and swings his legs back into a plank - very impressive! Since I started these workouts I have seen improvement in my flexibility and my mid-section is looking better too.

The hardest workout I do is Bob Harper’s Total Body Transformation, a full hour of non-stop action.  There isn’t much of a warm-up but the first quarter of the workout is not too hard.  This part features a lot of work for shoulders – great for the often-weak rotator cuff areas.  The rest of the workout is more about legs and core, including a fair number of isometric moves using planks and squats.  It’s a good workout but a bit unrealistic; toward the end, even the people in the class are starting to lose their form. I alternate this with Bob Harper’s Totally Ripped Core, which is supposed to be mainly for abs.  With these two workouts the main change I have seen has been in the backs and sides of my legs. My quads are naturally strong but these workouts have helped my hamstrings and abductors especially.  I can now lift my top leg while doing a side plank, which I couldn’t do before.

I do at least one of these workouts six days a week.  Twice a week I also have to do 30+ minutes of cardio because none of these workouts gets my heart rate much above 120 bpm and I need to get into the low 130’s to maintain condition.

Do You Take Supplements? Use Generic Drugs? Check Out ConsumerLab.

There is so much information out there about supplements – which ones we should take and how much of each, whether we should take them at all – that it can be different to sort out the facts from the rhetoric and self-promotion. If you want to know what the science says, check out ConsumerLab. Founded in 1999, this organization tests supplements to determine whether they actually contain what the label says and not too much or too little of it, that they aren’t contaminated by toxins such as heavy metals (found in some calcium supplements), and that they can be absorbed by the body. Tod Cooperman, MD, president of ConsumerLab, appeared on Dr. Oz on 4/9/2013 discussing the mission of ConsumerLab and some recent findings. A follow-up article by Dr. Cooperman appears on the Dr. Oz web site.

The same program included a discussion of generic drugs, an area where I’ve had some personal experience. Dr. Cooperman pointed out that the FDA does not test generics for efficacy and safety; in fact it doesn’t test them at all. Manufacturers of generic drugs themselves test their products to ensure that they include approximately the same amount of active ingredient as the original drug.  "Approximately" in this case is defined as 80%-125%. Different manufacturers of generics may contain different percentages of the active ingredient so if you got generics from one place one month and another the next your dosage could vary by as much as 45%! This gets you into trouble with medications where it is important to stay within the same narrow range. Dr. Cooperman listed the following groups of drugs:

1.       Blood pressure

2.       Thyroid

3.       Anti-seizure

4.       Asthma

5.       Blood thinners

6.       Immunosuppressants

7.       Anti-depressants

In these cases generics should be used with caution. The same is true for extended release medications because the pills may differ in technology.  

Dr. Cooperman also recommended identifying the manufacturer of your generic by checking the label and trying to get the same kind each time. He also suggested asking whether there is an authorized generic for your medication. Authorized generics are made by the same company that originally produced the drug but after it has gone off patent. If you switch from a medication to a generic, he said, you should monitor yourself for a month to be sure that nothing has changed.

In my own case, it took years to get my thyroid level stabilized.  A couple of times I was put on generics instead of Synthroid and the results were bad.  These days I have a note in my doctor’s folder for me saying “Do Not Substitute.”

Update: Recent Bloomberg article about people's experiences with generics, https://bloom.bg/2HwQK0w

From Sharon Begley on Twitter

I follow science writer Sharon Begley on twitter and picked up references to a couple of recent articles on health care.  

Tuesday’s USA Today carried a long article:  “DoctorsPerform Thousands of Unnecessary Surgeries” by Peter Eisler and Barbara Hansen.  One man had his dreams of a career in professional baseball and the military shattered after he had a pacemaker installed.  It turned out that all he really needed was blood pressure medication.

On the website ModernHealthcare.com Jason Shafrin interviews author and economics professor  Douglas Hough about his recent book on irrational behavior of patients, providers, and stakeholders.